access strategies, approximately 2 thousand enroll lees will transfer without the need to apply. this graphic shows the estimates of coverage transitions for healthy san francisco and sf path members under health reform. you'll see at the top, about 60 thousand members are currently enrolled in healthy san francisco or sf path, we estimate that about two-thirds of them, 40 thousand 500 will be eligible for some kind of health insurance. 28 thousand will be eligible for medi cal and 12 thousand 500 will be eligible for covered california, 19 thousand 500 will be ineligible for coverage, those will be the undocumented residents or people who have other reasons not being subject to the mandate. eligibility does not equal an enrollment and people will have to actively enroll into health insurance to get the coverage they are entitled to, so of the

40 thousand 500 we think are eligible, about 25 thousand will access insurance. this is based on a 62.5% rate of retention that we currently experience in the healthy san francisco program, so we have anticipate hated our retention rate which is quite good for our program will translate into health insurance enrollment. this leaves about 15 thousand 500 who represent those who may be eligible but do not enroll in health insurance. and they might not enroll for any number of reasons, enrollment is complex, they may choose to pay the penalty rather than enroll in insurance, they may choose to pay the penalty rather than enroll in insurance, this group plus the 29% that are not already in sf path are the individuals we will have to focus our outreach efforts on.

>> just a quick question. do you have any more specific information on the 35 thousand that you're talking about in terms of, you know, what that group looks like, any demographics, ethnicity, lgbt or not, do you have a sense? >> we do, and i will -- 19 thousand 500 of them are largely going to be undocumented residents we anticipate. they may be other people who are not subject to the mandate because of hardship or other reasons but largely undocumented. the 15 thousand 500 will likely be those that are at the highly end of the healthy san francisco limit, it cares for people up to 500 % of poverty and those who are medi cal eligible will be able to apply to medi cal without no cost to thel, so that will be an easy decision, as the income gets higher, the cost sharing gets higher. >> what percentage will be lgbt?

>> i do not have that percentage. >> thank you. >> within the department of public health, we really have a two-fold focus on health reform implementation. first is about dph's own health care delivery system. we are looking to ready our system to be the provider of choice for our patients, our uninsured parents have not had a wide choice of health care providers but health insurance provides them with that choice, we want them to choose us. a recent survey indicated that 60% of low-income individuals who are uninsured would change their provider if they were given the choice to do so so we are responding to that challenge and integrating the service we offer throughout our delivery system so we do a better job to coordinate the care our patients need, we're working to improve quality and capacity to increase access to care, we're enhancing our patient's experience by shortening waiting times and

increasing our efficiency in customer service and these are exactly the items that barbara is at the health department working on today. our second role is more citywide in nature and related to our mission to protect and promote the health of all san franciscans, we're maximizing enrollment into the health insurance options under the nca and i'll focus on this a little bit more. the health department has identified several key factors to the successful implementation of the aca in san francisco. the first is personal responsibility, this is not just the requirement under the individual mandate but our civic duty to ensure we step forward and enroll in health insurance. i have a friend that says everyone in san francisco was born with a participatory governance card and we need to be mindful of our role in ensuring health reform's success. we also need to be mindful of

how we discuss affordability in this context, it's not to discourage people in enrolling in health insurance, we need everyone to enroll. second we need to ensure successful transitions of uninsured to health insurance, because we know who the majority of our uninsured are and how to contact them, thanks to healthy san francisco, we have several healthy san francisco initiatives under way to ensure this successful transition. i've been saying that healthy san francisco is now not only a health care access program but a coverage conversion program. we've been highlighting health reform messages and our participant newsletter, we have a website on information on health reform readiness, we're launching a text messaging campaign this summer for retention, we're training sf path s*us mer services to answer questions regarding health reform, we're spearheading a citywide campaign to ensure all healthy

san francisco participants can apply for any insurance in which they're eligible at any of our 33 enrollment sites throughout the city and partnering with the human service agency for communication and is staff training, behind the scenes, we're working to provide a smooth transition into medi cal. we need to do targeted out lao*efp to certain populations, and that's to the question you asked earlier, who are the uninsured who need the most outreach. san francisco applied for an education grant and was not awarded the grant due to our significant process in reaching out to our uninsured, it identified those special populations that are most likely to be uninsured and may require special outreach, young adults are critical to health reforms success, younger healthier people are critical

to balance out the older who are often sicker and help keep costs down for the whole system and will eventually lower prices overall. latino and asian adults with a specific focus on chinese adults, information from covered california will be available only in english and spanish and not chinese so this will require a local effort, residents of the southeast corridor and small business -- small proprietors and other businesses, the final is messaging, and this is the simple three step message that we've been saying all along, new opportunities for health insurance coverage are coming and we are here to help you. health insurance is better than healthy san francisco if you qualify for it, but if you don't qualify for it, healthy san francisco will be here to help you. so, the timing of these transitions, in june of 2013,

cover california identified the five plans that will be offered in san francisco which i named earlier, in october of 2013 as the supervisor indicated earlier, open enrollment begins for medi cal and covered california. in january of 2014, the sf paths program ends, the individual mandate begins and we transition 10 thousand people on that one day into medi cal. and then between january of 2014 and december of 2014 and really ongoing after that, about 25 to 40 thousand healthy san francisco participants will transition to the insurance for which they qualify. at this point, i will turn it over to noel sim mos to talk about implementation at sha. >> good afternoon, supervisor, noel simmons, deputy director at the human services agency, just to round out the picture of what city act sis are doing to prepare for health care

reform, i have three slides to share with you about the efforts at sha, in many other jurs dictionary, the health and human services departments are separate, of course -- combined, of course here we're separate to most folks don't understand that they have a mandated roll in implementing health care reform, we have four primary charges, the first is to conduct eligibility for medi cal and exchange tax credits, for customers who will be applying in person online by phone e-mail or fax, that's a responsibility that we have today, we'll be expanding to the new expanded eligibility and is the exchange population on october 1. secondly, to accept warm hand offs, when a client calls looking for coverage, they'll be screened by the state call center and if appears that they are likely to be medi cal

eligible, those calls will be transferred to us at the county level to process those eligibility requirements. thirdly, providing ongoing case management for all medi cal programs which we do today, and then finally enrolling customers into all programs for which they are eligible, by which i mean not just health coverage programs but over the long term, all other social services programs including cal fresh and calworks, this is a process that's known as horizontal integration, the affordable care act encouraged but did not mandate horizontal integration, the state of california has embraced that vision and it is the vision that we are holding front and center as we move forward with implementation. social service agencies including hsa are undergoing a culture change in anticipation of health care reform. the question is no longer whether a client is eligible for benefits but rather for what is a client eligible.

we are moving as mentioned to a service center business model in which any worker will be able to handle any customer need and in which all doors will lead to coverage. our goal is to provide first class customer service and this includes coordinating with other social service for which people may be eligible. we are currently engaged in hiring and training a number of new staff in ants pace of enrolling over 30 thousand new clients into health coverage beginning in october. we are transitioning to a service center environment which involves reworking all of our business processes and implementing a whole fleet of technology that is are intended to help our workers do their job more efficiency but to enhance the customer experience. we are conducting outreach to the new medi cal eligibles who are already on the hsa caseload, we know today we have 7 thousand or so county adult

assistance program, ga recipients who are eligible for medi cal, 25 thousand additional ones will be likely to be eligible for medi cal, so we will be doing a lot of concerted outreach through channels to those folks and we are doing a lot of coordination with stakeholders both inside the city, family and external to make sure we effectively transition healthy san francisco and path clients to medi cal into the exchange and make sure we do a lot of outreach to our target populations, that concludes the presentation, i know both colleen and i would be happy to answer questions. >> supervisor mar, any questions? >> i wanted to ask a couple of questions of our deputy director. my understanding is that mayor lee reinstituted the health

council, and i wanted to know if you could talk a little bit about that, what the purpose or the role of the council will be going forward? >> yes, you're correct, the mayor announced this morning the reconstitution of the universal health care council, it will be led by director goober see ya, it will look at aca implementation in san francisco to maximize enrollment into health insurance and we'll look at the intersection of the sca, we anticipate that it will be convened this summer and may run for a couple of months, two or three months. >> one of the things that has been speculated is that maybe the council will look at the issue of gaps and i was wondering if you could talk a little bit about that. >> that is true, to look at what our local ordinances cover, what the health care --

what the affordable care act covers and what gaps there might be based on local policies that have already been put into effect about our health care priorities where there might be opportunity tos fill those gaps. >> i'm wondering if you can talk a little bit more about gaps, you know what we mean by gaps, i know there's been some issue at the state level with medi cal because of substantial cuts due to the budget crisis that the state has faced that has placed additional requirements on individuals, can you talk a little bit about that. >> i think you mentioned a couple of them earlier today, for example, the employer provisions of the aca start at 50fte's for large employers, the health care security ordinance covers employers down to 20fte's, as you mentioned, the asa pertain tos 30 -- fte's working 30 hours a week where

ours look at them working 8 hours a week, affordability needs to be discuss ined this context. the 15 thousand 500 folks that will remain uninsured and will choose not to enroll, some of those reasons may be unaffordability. >> will there be medi cal el jebl folks that will be impacted by costs as well? >> for the newly eligible, they will have no cost to medi cal, so they will have no premising and their cost sharing will be fairly minimal. >> and to the extent there's been some cost shifting under medi cal at the state, will that impact any individuals? >> i think the cost shifting at this state, it's been provides, california has very, very rates

for providers, 59th in the nation, i believe, and that translates to access, so individual access to people for medi cal to the services they provide that they need, sorry. >> and just a couple of questions about the employer spending requirement, from the per specie of the department of public health, how could the employer spending requirement benefit employees that may fall within the 35 thousand, 15 thousand, you know, 19 thousand? >> so, certainly the employer spending requirement does many thing, it allows for people to get health insurance which is primarily how it's used. most of the employer spending requirement is spent to purchase health insurance for employees, it can also be used as you know for the city option which can support their enrollment in healthy san francisco which doesn't mean the individual mandate, but the mra aoption under the city

option can be used to purchase health insurance premiums for individuals. >> i see, and one of the things that i remember and i wasn't on the board when this happened, do you remember reading about dr. cats that served as the director of public health at the time and i remember him explaining how the employer spending requirement was a critical component of insuring equitable financing of health care and it would make sure it maximized coverage of as many people as possible fr. the perspective of the department of public health, i mean, does the passing of the hca change that? >> well, i'm not sure if it changes that. i think they do similar things, both of them have incentives or

mandates for employers to expand health insurance coverage, so i think that they do similar things. in terms of the employer spending requirement specifically on the department, it's only one funding source of healthy san francisco as you said earlier and relatively small funding source for san francisco. >> and how much of a funding source is it, how much of the budget for healthy san francisco comes from the employer spending requirement? >> the employer spending requirement is about 14 million dollars to the healthy san francisco program. city general fund covers the healthy san francisco program at about 77 million dollars, and individual providers who as you know healthy san francisco is a leveraged program with hospital charity care, the value of those services are about 38 million dollars, all told, it eats a little over 100 million dollar program with about 14 million coming from employer spending requirement.

>> just a final question related to that. if the -- without the employer spending requirement, where would the 14 million dollars come from, would that have to come from the general fund? >> it would likely have to come from the general fund but it would be a likely smaller program, there would be fewer people in healthy san francisco, we know they'll have less enrollment moving into the future so it would be a smaller program as well. >> colleagues, any other questions? okay, great. now, i'd like to call on the office of labor, standards and enforcement. i see mr. gold berg is here. >> good afternoon, supervisors, my name is matt gold berg and i'm here to answer any questions you have about the employer spending requirement or any of our work on the health care security ordinance. >> and by the way, i want to

okay naj that we have been joined by supervisor mali ya cohen who has been chairing another prior meeting and so since 10:00, yes, and lucky we let paid by the hour at the board of supervisors, so that makes it easier, so mr. gold badgering, maybe the place to start is maybe if you can explain how the employer spending requirement works? >> sure, as you said earlier, supervisor campos in your introductory remarks, the security ordinance established the healthy san francisco program, it created the employer spending requirement, it's been in effect since 2008. the principle obligation or mandate soeshtd witched the employer spending requirement is that covered employers are required to make mandatory health care expenditures on behalf of their covered employees, so there's a few legal definitions embed ined that statement. the employer that is are covered by the law are those

with more than 20 employees, and that's worldwide, you could have a single employee here in san francisco but if you're more than 20 employees throughout the country, the single employee here in san francisco would be covered by the spending requirement. i've been saying 20, the mandate is 50 employees for the non-profits, so 20 employees for profit companies. the covered employees are those who work here in san francisco more than 8 hours per week and have been employed either employed for more than 90 day, so those coveresed employees are entitled to these mandatory health care expenditures made by the employer. the amount of money that any individual employer is required to spend is based on a particular rate that changes each year, currently there are two rates in play for 2013, large employers, those with

more than 100 employees are required to spend $2.33 per hour for these covered employees whereas smaller employers, those in the 20 to 99 range are required to spend $1.55 per hour on health care for their employers. i guess finally i would say just in the spirit of an overview, principally we see that employers make health care expenditures in a few different ways, we think of three general categories, the largest of those categories and i think the preferred route is that employers provide health insurance to their employees. we collect data on an annual basis from employers about how they're making these expenditure sos we know the vast majority of expenditures toward this requirement are made toward health insurance, approximately 90%. the next sort of category of expenditures as has been alluded to earlier, a number of employers contribute directly

to the city option which affords their workers reduced fee or free enrollment in healthy san francisco program or for those who are not eligible for healthy san francisco, a medical reimbursement account and we see that approximately 3% of all the expenditures under the employer spending requirement go toward that city option and then finally the third sort of category or bucket are these reimbursement program that is are typically administered by third parttys on behalf of employers and we see that in the range of 6 or 7% of the overall health care spending goes into those health reimbursement sketches and those are then accessed by employees to be refunded for any out of pocket medical expense that is they occur. >> and i know at the board of supervisors as some of my colleagues remember, there was i guess a little bit of a difference of opinion if you will among friends in terming

of how to deal with health reimbursement accounts. i'm wondering if you can taug a little bit about what has happened around health reimbursement accounts, there were many of us who at the time we were trying to close this loophole who were saying, listen, the federal government will eventually see these accounts for what they are and probably will not allow them to exist which is why we wanted to close the loophole, i wonder if you can talk a little bit about that. >> by way of additional background, our office is required by the health care security ordinance to collect data from the employer community on an annual basis, every year we collect that data and analyze it and we saw in saw over time that the amount of money that was being contributed to these health reimbursement accounts was going a large amount of that money was going unused by employees, that was sort of one

data element that fed into a policy discussion here at the board and the mayor's office that led to an amendment to the ordinance so the practices around health reimbursement accounts have changed in some respects commencing in 2012. >> how are health reimbursement accounts treated under the aca? >> recent federal guidance has come out to indicate that initially stand alone health reimbursement accounts and this is the practice here in san francisco in particular, these accounts are not coupled with health insurance coverage but they're provided on their own to employees. the latest guidance from the federal government indicate that is those health reimbursement accounts are going to be imper message under the health care act under violation of the larger principle that the affordable health care act has eliminated the use of any health care programs that have lifetime or

annual caps, and stand alone health reimbursement accounts by their definition have annual caps on the benefits and as such, it's been widely understood and interpreted following this most recent federal guidance that these will be impermissible commencing in 2014. >> i think for many of us, that's a good thing. now, if maybe for purposes of informing us, i know that when the debate around the loophole was happening, there was a different approach that was taken, as you know, i introduced legislation which mayor lee vetoed and there was sort of a revised legislation that was introduced and eventually passed and one of the things i want to ask you, and i remember that this was a key component of that legislation, and i will sort of read to you something that was includes, something that the mayor said at the time and the passage of the version of the

legislation that was passed and was signed and he said, we must know what proportion of companies, however small, are placing these unfair restrictions on their employee, hra's, if we find after collecting statistically significant data samples that there are more than just a handful of employers who are unduly restricting employee hra's, i will work with the board of supervisors to place additional regulations governing hra's. did we collect the data to know whether or not restrictions were placed by employers? >> yeah, we certainly did, supervisor campos. the amendment, the ordinance was passed in november of 2011. i think the may yoirl executive directive calling on us to give that direction was called shortly thereafter, so early in

2012 when we commenced [inaudible] how they complied with the ordinance in 2011, for the first time, we leaked data about health reimbursement accounts and specifically whether and how those accounts were being restricted. and the data that we then reported based on the 2011 practices showed that 53% of employers who administered these health reimbursement accounts had imposed one or more restrictions on them, and by restrictions, what i mean here is the employees who had these accounts were prevented from using them for certain particular types of medical expenses. >> so, that i understand, so before the law was passed by the mayor and the board in 2011, the percentage in terms of employers who placed restrictions was what, 53? >> 53% >> and what happened the year after? >> we're now in the process, we

collected the data that was submitted to us earlier this year, we'll shortly be releasing our annual analysis of that but we have a preliminary look at the date that was provided to us from 2012 and the number hasn't changed, essentially 53% of employers continue to report that they place 1 restrictions on their health reimbursement accounts. >> so, no change even after passage of that? >> no change even after passage. i would point out that there was some understanding at the time of passage that the board's hands were tied and as a result there was nothing in the ordinance that specifically was tattered at trying to reduce those estruses. i think there was some belief or hope in various communities and circles that that practice would maybe decline over time, but again, with this first year where we have now comparative data across 2011, 2012, it

continues to be more than half restrict, we can drill down and show that there are major categories of restrictions and i think there was particular interest in the percentage of employers who would restrict their use for health insurance swes for enrollment in healthy san francisco because if you're an employee who receives a health reimbursement account from an employer in lieu of health insurance, it would be expected or common that you might utilize those funds to purchase health insurance on the private market or enroll yourself in a healthy san francisco program, i think that's more likely to be true after 2014 when individuals have a legal mandate to provide that insurance and the rates we see 35% of these health reimbursement accounts precluded or prevented employees from using the funds to purchase health insurance and 28% of them precluded individuals from using the